KRAS-variant Order Form CLIA-CERTIFIED LAB Step 1 of 11 9% Name* First Last Email* Enter Email Confirm Email Would you like:* To know my KRAS-variant Results and to submit my DNA for research studies, $129 To know my KRAS-variant Results, $159 To receive a test kit to send in my sample for research studies only, $0 To know my KRAS-variant Results and to submit my DNA for research studies, and I was in a previous study OR I need financial assistance Which one applies to you:* I was in a previous study I need financial assistance A $15 Processing Fee is required.$30 is the minimum fee.Please explain why you need financial assistance at this time:*Common Questions Why would I submit my DNA for research? By joining a MiraKind study, you can play a role in helping MiraKind answer some of the most pressing questions associated with risk of disease in individuals. We are on a mission to better understand the behaviors, environmental factors, and lifestyle choices that can influence an individual’s risk of cancer, and your participation in a study helps us get closer to finding the answers to improve health for all individuals with the KRAS-variant, as well as to understand new mutations like the KRAS-variant. What do I need to know if submit my sample to a study? To participate in our research studies, you'll need to complete a survey that takes about 15 minutes, if you have not yet. You'll also need to read the consent in this form and agree. We may contact you in the future with follow-up questions. Do you need financial assistance? Please contact Dr. Joanne Weidhaas here. Reason(s) for testing, check all that apply:* Personal history of cancer Family history of cancer Personal or family history of more than one cancer in an individual (multiple primary cancer) To help guide the decision regarding hormone replacement therapy Current cancer diagnosis for information to help guide the decision on treatment choice IMPORTANT NOTE: If you received an email from MiraKind about sending in your sample the answer to the next question is YES.Have you already taken a survey to participate in a study and need a kit to send your sample in?* Yes No Before you order, please note that a physician must deliver your test results. Be sure to have your physician's phone and fax number ready. IMPORTANT: After submitting your information, you will need to complete a 15 minute survey so we have the information and permission we need for using your sample in our studies. Completion of the survey is required. Phone Number* Your current SHIPPING Address*We currently ship to the Unites States. If you need a test kit shipped to another country, please do not complete this form and contact us at firstname.lastname@example.org. 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I understand that a positive test result serves only as a predictor of risk or response. I understand that a negative test results does not assure no risk or response. I understand a physician must deliver my results to me. I consent to being tested for the KRAS-variant. I understand the benefits and limitations of the testing to be performed as indicated. I understand that a positive test result serves only as a predictor of risk or response. I understand that a negative test results does not assure no risk or response. I understand a physician must deliver my results to me. I consent to being tested for the KRAS-variant. I consent for my genetic sample to be used in MiraKind research studies. I understand my personal information will never be shared. I consent for my genetic sample to be used in any MiraKind research studies. I understand my personal information will never be shared. Click here to review the consent document. I have read this form and decided that I will participate in the study described above. Its general purposes, the particulars of involvement and possible hazards and inconveniences have been explained to my satisfaction. I understand I will be emailed a PDF copy of the consent document. I agree that I have read and accept the above terms* I agree I acknowledge I am responsible for $159 when I submit this form. I understand my individual results and information will never be shared without my permission. I do give MiraKind consent to release my results to my chosen physician.* I agree I acknowledge I am responsible for $129 when I submit this form. I understand my individual results and information will never be shared without my permission. I do give MiraKind consent to release my results to my chosen physician.* I agree MiraKind is an independent nonprofit that runs studies to answer questions about cancer for individuals and their families with novel germline mutations. I would like to be signed up for the MiraKind newsletter to keep up to date on studies and results from studies.* Yes, please subscribe me No thanks KRAS-variant Test Price: KRAS-variant Test with Study Submission Price: Processing Fee* Price: KRAS-variant Test Kit with Financial Assistance* Please enter in the amount you can pay at this time. $30 minimum.Total $0.00 Credit Card*Card Details Cardholder Name Almost done! Please click "Send" only ONE TIME to complete your order. Give the system a minute or so to process your order and then you will be redirected to a success page. Thank you! Once you click send you will be redirected to our study survey.